jwilzewske: geriatrics

Showing posts with label geriatrics. Show all posts

Sunday, June 1, 2008

Assistive Technologies 3: Music Is the Prosthesis

Gospel Choir, Abyssinian Baptist Church, World Science Festival, New York, 31-MAY-2008

M usic has a unique ability to animate us, to initiate activity for people who are stuck for one reason or another. And it has a unique ability to help us to feel community with others, to bind us together and to reveal and restore bonds that were broken. These are true for all people. But they are true also for people who have diseases, whose bodies prevent them from starting on their own. Stutterers who cannot speak can, amazingly, sing perfectly. People with viral encephalitis lethargica, about whom I wrote in my book ‘Awakenings’, are helped greatly by music. The power of drugs to help—this waxes and wanes. But the power of music never diminishes. With Parkinson’s, the music must only have a beat, a clear-cut rhythm, to get the person un-stuck. With Alzheimer’s, the music must also be familiar music, music from a time in the person’s life before the dementia. Even with advanced dementia, when powers of memory and language are lost, people will respond to music. With a song, it is possible to discover that words are still in there. Finding that out can be very reassuring, say, to a person who has been unable, for 2 years or more, to call forth words to speak. Then, once we know that the words are still there, it is our task to see whether we can elicit them at other times [when music is not there] and make them available for general use [once again]. It is the basal ganglia, the brainstem, the cerebellum, and some parts of the motor cortex; it is the mammalian old hindbrain. That is where these music-related connections are, and why the ability for music to liberate a person is impervious to diseases that destroy other parts of the brain, the intellect. Actually, I say ‘mammalian’, but every time I do someone tells me about ... cockatoos. Perhaps it is not just mammals...”
— Oliver Sacks, Abyssinian Baptist Church, New York, 31-MAY-2008.

There is a tendency to place too much emphasis on thought—on higher brain functions and deliberation and intellect—when we think of how we understand and respond to music. To counterbalance that tendency, neurologist-author Oliver Sacks spoke yesterday at the Abyssinian Baptist Church in Harlem, New York, in one of the events that comprise the World Science Festival. The two-hour program featured a performance of many selections of gospel music by the church's 53-member Abyssinian Baptist Choir. There was a standing-room-only sold-out crowd of more than 1,000 in attendance for the event. The World Science Festival was conceived by Columbia University physicist Brian Greene and his wife, Tracy Day, who is a broadcast journalist.

Over My Head (Arr., R. Jennings)
Woke Up This Morning (Arr., J. Bolding)
We’ve Come This Far by Faith (Arr., J. Bolding)
Lift Every Voice and Sing (Arr., R. Carter)
Order My Steps (G. Burleigh)
Total Praise (R. Smallwood)
That’s How the Lord Works (Arr., J. Bolding)
Didn’t My Lord Deliver Daniel! (Arr., J. Bolding)
For Every Mountain (Arr., J. Bolding)
This Little Light of Mine (African American Spiritual)

Two CMT posts last month concerned assistive technogies, to help disabled people regain and maintain abilities to perform music, particularly in a chamber music setting. But the Abyssinian Baptist Choir concert last night and Dr. Oliver Sacks’s and Rev. Dr. Calvin Butts’s talks (and this CMT post) are reminders that music itself is an assistive technology that promotes the health of the individual and the well-being of the community/society.

Consider, too, that a dimension of the ‘intimacy’ that is definitional of chamber music idioms is that chamber music is assistive in connecting each of us with our true selves—it induces an intimacy of self-awareness, self-discovery, self-actualization. In other words, the intimacy of chamber music is not purely discursive, interpersonal intimacy. It is intra-personal as well; it is about intimate identity. Those who, through the ravages of Alzheimer’s or stroke or other conditions, have lost their memory of their own personal history or identity know this more acutely than the rest of us. The amount of the processing of musical stimuli (and the amount of the synaptic storage and processing associated with personhood and identity) that is located in lateral prefrontal regions, in motor cortex, and in the amygdala, hippocampus, and other limbic structures (ones that are only tangentially connected with intellect or volition) in the brain is suprising, as Grahn and others have recently observed in their fMRI imaging studies. The heart of the emotional brain responds innately to psychophysiological stimuli associated with realistic musical scenes and animalistic rhythms—even the mere suggestion of rhythms or songs, as Sacks says. Our true selves are (partly; substantially) down in those non-intellectual structures, too.

Those who, through Parkinson’s or other diseases, have lost their ability to initiate actions that manifest their will and their personhood also know that music can assist or restore these—a major point of Oliver Sacks’s remarks. There is a physiologic immanence that is fundamental to music—the rhythm of music is the vehicle for it, more than melody or harmony. The latter are ‘added bonuses’, as Sacks put it. Gospel singing is, apart from its other notable features, inherently physical, intensely rhythmic, radically anticipative, contagious.

The ‘intimacy’ of gospel singing as a species of chamber music is also inherently communitarian—the solidarity and support and intimate belonging and acoustically-mediated enclosedness of the congregation; the musical rhythm-enforced inclusiveness that accepts divergence and difference ( ‘alterity’ ). At one point during last night’s performance, one of the women Abyssinian Baptist Church congregants leapt into the aisle and began shaking and shouting ecstatically. Two of the ushers stood by, but the woman did not collapse. So moved by the music, she continued her rhythmic ‘speaking-in-tongues’ shouting and shaking, at a decibel level often exceeding that of the large choir. The chamber culture and the chamber singers welcome this and recognize and assimilate it as part of the intimacy of worship in community. Sacks recommended that musical training in the schools should be a major curriculum priority, given the large social and health benefits that are known to be associated with engagement with music. In enthusiastic agreement with this remark, the crowd cheered and gave Sacks a standing ovation.

S teven Mithen has written about this … his experience of discovering his own musicality. He was humiliated when attempting to sing as a child, and stayed away from singing for more than 30 years. Now in his forties, he decided he would take singing lessons for one year. Before he began, he got an fMRI scan of his brain. And, after singing for a year, he arranged to get another fMRI. The corpus callosum and other parts of his brain had dramatically changed in size. The changes were obvious. And it has been found in other musicians, too. We could look at fMRI scans of Albert Einstein’s brain or Brian Greene’s brain, and you could not tell the difference between the brains of mathematical physicists or cosmologists and the brains of ordinary people. But I dare say if you got an fMRI of any of the people behind me [gestures toward Abyssinian Choir members in loft] and you would say ‘This must be the brain of a musician’. It is that dramatic. Of course, it is not yet clear how much of this difference is due to genetics—music-induced structural differences in those who have already musical potential—and how much is from the musical training. But the effect is real. Engaging in music changes your brain.”
— Oliver Sacks, Abyssinian Baptist Church, New York, 31-MAY-2008.

The World Science Festival programs continue today with a performance by jazz singer Marilyn Maye (born in Wichita in 1930) at the Kimmel Center, with lectures by Robert Butler, David Sinclair, and Richard Weindruch entitled ‘90 Is the New 50: The Science of Longevity’ at the Eisner & Lubin Auditorium at NYU—how music may help us to live longer, in addition to helping keep our wits and our initiative and our community.

W hat we have been studying ... is that when you pray, there’s actually a physiological change in the body. Music is very much a part of this. There are certain notes that generate in the human body a kind of peacefulness.”
— Rev. Dr. Calvin Butts III, pastor, Abyssinian Baptist Church, New York, 31-MAY-2008.

Tuesday, May 27, 2008

Assistive Technologies: Wheelchair Transfers to Piano with ‘Slide Board’

M y mother who is 86 is now wheelchair-bound. Transfers are difficult for her, and her severe osteoporosis means that any fall carries a high risk. But she desperately misses playing the piano. She was a music teacher for many years, and playing music is perhaps the very most important thing in terms of quality-of-life for her. She used to play in the morning before breakfast, for a couple of hours in the morning, a good hour or two in the afternoon, and then after dinner for at least an hour before bedtime. She does not have much upper-body strength, and she is a bit overweight. But she is just not herself since the wheelchair plus her diminished mobility have prevented her from getting safely and easily from the wheelchair onto a chair of the proper height or a piano bench. I can’t seem to get her out of this deep funk she’s been in since the wheelchair. Are there any products that might enable her to do transfers safely from the wheelchair to a chair at the piano, or enable her to do it with the help of a caregiver who is not very strong? I’m at my wits’ end. And the people at the Assisted Living facility where my mom now lives, while they are well-intentioned, seem to know nothing about assistive techniques for musicians. They do fine with your garden-variety Alzheimer’s or stroke victim, but nothing at all for something so simple as a frail, elderly pianist.”
— Anonymous.

There are actually quite a few practical assistive-technology options these days, to enable your mother to continue to play—with the caveats you mention about the caregivers’ and your mom’s limited upper-body strength to accomplish safe transfers. The links below may enable you to explore (with your mother and with her caregivers) which one(s) might be best.

Besides the ‘assistive-technology’ devices, the following factors should always be considered for wheelchair transfers in general. Some of these you already mentioned in your email.

Determine if the assisting person is physically able to help an individual complete the transfers safely.
Encourage the individual being transferred to assist as much as possible.
If the person to be transferred is not strong enough to assist very much, use a ‘gait belt’ for the safety of both the person being transferred and the person assisting with the transfer. (A gait belt is a heavy strap or harness which is placed around the waist of the individual to be transferred so that the assisting person can have a safe hold without pulling on clothes or arms and without straining her/his back.)
If the individual to be transferred has sufficient arm strength, use a ‘slide board’ (a narrow, long wooden or plastic board with a smooth surface). Placed under the upper thigh, it allows the individual to push with their arms and slide themselves over the slide board ‘bridge’ to the destination sitting surface (see photo above).
Raise the height of sitting surfaces for ease and safety when transferring (place an extra cushion on the piano bench or chair).
Practice with an extra person standing-by to assist. Do this for a sufficient number of times, until a routine is established for minimally-assisted transfers and both the person being transferred and the caregivers are confident and proficient. Periodically observe and re-observe transfer technique, to be sure that the person and her caregivers do not become complacent in regard to proper transfer technique or begin taking unsafe short-cuts.
Remember, if you are doubtful about completing the transfer safely, call for more assistance rather than risk injury to the individual or to yourself.

[Slide boards and gait belts are available at most medical supply stores.]

The slide boards I’ve found work best are the heavy-duty ‘S-shaped’ plastic ones like the BeasyTrans™ product. They enable the wheelchair to dock with the [modified, weighted] piano bench or chair at a convenient angle, such that the caregiver is not cramped or colliding with the piano. Slip-resistant foam pads on the under-side of each end of the plastic slide board increase stability during transfers and, when the person’s weight is on the board, insure that the board has a good frictional hold on the wheelchair and on the destination chair surfaces. Wooden slide boards are okay as well, but they may be more difficult to clean and tend not to work as smoothly as the plastic ones. Make sure that the slide board you get is at least 65 cm long. Shorter ones make the transfer to and from a piano bench or chair more awkward, in my experience. And, if the slide board has a top unit and a bottom unit with a ‘bearing/slider mechanism’ in between, a shorter board’s mechanism may be prone ‘stick’ if the difference between the wheelchair’s height and the piano seat’s height is significant. If possible, you and your mom may want to ‘try before you buy’ in a medical supply store.

Basic Guidelines for Wheelchair Transfers

Make certain the wheelchair wheels are firmly locked/braked.
Encourage the individual to ‘scoot’ toward edge of chair/seat as much as possible.
Position yourself into proper body mechanics stance (knees bent, arch in lower back) while holding onto waistband or gait belt, before you begin to assist in transferring the person.
Be sure the individual understands where he/she is going to move to.
Ensure that the individual is ‘ready’ to begin the transfer.
Prepare the individual for a coordinated transfer by asking her/him to move ‘on the count of 3’.
Have the individual push up with arms from sitting surface as able.
Avoid allowing the individual to attempt to put arms around neck or shoulders of the transfer assistant as this may cause neck or back injuries.
Maintain proper body mechanics while pivoting with the individual.

The piano bench or chair that is the destination for the ‘to’ transfer is another issue altogether. Most benches or chairs have a poor center-of-gravity and are too prone to tipping over. A local machine shop or cabinetry maker can be engaged to make different legs for your mother’s favorite piano bench or chair, to attach ballast weights at floor level (say, 5 kg steel or lead weight per leg) with ‘block’ feet 10 cm square or more so that the chair will not tip. You may want to have a ‘grab bar’ added to an existing bench that you have, so that there is an obvious and reliable grip for your mom to aim for as the transfer proceeds. (Grabbing the piano around the keyboard is obviously not safe or reliable.)

Alternatively, you may wish to try one of the ready-made rehab ‘transfer benches’, which are usually used in showers for bathing. These are relatively inexpensive and can be fitted with a nice-looking, comfortable cushion and adjusted to a proper height for use at the piano. The visual aesthetics may not be quite as nice as a normal piano bench, but functionally it will serve the purpose well. Surprisingly, not many rehab therapists think of using a piece of equipment designed for the bath in locations outside the bathroom. It’s just a piece of furniture! No reason not to have two—one in the shower, and one at the piano!

Bath grab-bar, which machine shop can modify to attach to piano bench

I hope this information helps! (The suggestions above are pertinent not only to piano but to transfers to benches or chairs used by people who perform on other instruments as well. Pertinent to wheelchair-bound individuals of any age, not just older people.) The dignity and mental and emotional health of your mom depend on your meeting this challenge together with her. Continuing to play as long as possible is very important. I know this first-hand. My own maternal grandmother who had severe Alzheimer’s was able to continue playing piano long after she was unable to participate in conversations or recognize family members. Her memory for piano pieces she had memorized in the 1920s through the 1970s was, most amazingly, intact. Alice’s interpretive ability and phrasing, etc., were also preserved until just a few weeks before she passed away. The praise and appreciation she received from other nursing-home residents and family members kept her spirits up, offsetting the losses and frustrations she experienced in other dimensions of her life. Thank you so much for your email/question!